4/14/2018 LEARNING OBJECTIVES

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1 T H E L O W F O D M A P D I E T K E L L E Y W I L S O N M S, R D N, C N S C U W H E A LT H D I G E S T I V E H E A LT H C E N T E R LEARNING OBJECTIVES 1. Understand the basics of FODMAPs and their impact on gastrointestinal symptoms 2. Develop knowledge to manage FODMAP intolerances in the hospitalized patient 3. Identify patients who may benefit from a low FODMAP diet approach 4. Use proper resources for the low FODMAP diet approach 1

2 T H E S CIENCE O F FODMA PS DEFINING FODMAPS Fermentable Oligo-, Di-, Mono-saccharides And Polyols Fermentation: the chemical breakdown of an energy-rich compound by a microorganism Saccharides and polyols are types of carbohydrates There are 4 main types of FODMAPS Lactose a disaccharide Fructose a monosaccharide Polyols termed a sugar alcohol, can be further divided Oligosaccharides specifically dietary fiber, includes fructans and galactans types FODMAPs are found in many foods PHYSIOLOGY OF FODMAPS AND DIGESTIVE SYMPTOMS FODMAPs are poorly absorbed by the small intestine WHY? WKA6 Some are not meant to be digested and absorbed Lack or shortage of digestive enzymes Abnormal intestinal transit time Damaged intestinal lining Short bowel syndrome Meal composition Some people are more sensitive to FODMAP malabsorption 2

3 Slide 6 WKA6 in healthy individuals, fructose malabsorbed in 34%, lactose in 16%, polyols in 60%, and oligos in EVERYONE Wilson Kelley A, 6/13/2017

4 PHYSIOLOGY OF FODMAPS AND DIGESTIVE SYMPTOMS Poorly absorbed FODMAPs pass into the large intestine, where they are rapidly fermented by bacteria and also lead to osmotic shifts Fermentation leads to the production of gas Osmosis = movement of water, in this case into the intestinal lumen This can lead to symptoms such as significant: Abdominal bloating and excess gas Diarrhea and/or constipation Abdominal pain Nausea, vomiting FODMAP Intolerance 3

5 FODMAP VIDEO EDUCATION What are FODMAPs FODMAPs and symptoms The low FODMAP diet FOODS WITH FODMAPS FODMAP group Lactose Fructose Polyols Oligos Rich sources Milk, ice cream, evaporated milk, dry milk powder, egg nog HFCS, honey, agave, fruit juice, mango, apples, pears, asparagus Sorbitol,mannitol, prunes, avocado, cauliflower, blackberries Onion, garlic, broccoli, legumes, almonds, oats It is rare to be intolerant to all 4 FODMAP groups KEY POINTS ABOUT FODMAPS They are poorly absorbed, some of this is very normal When poorly absorbed FODMAPs lead to significant symptoms, patients are termed FODMAP intolerant FODMAPs act in a dose-dependent way FODMAPs are found in many foods, but all are carbohydrates Reducing FODMAP intake may improve digestive symptoms WKA1 4

6 Slide 12 WKA1 and there are many approaches to the diet which we will discuss in a little bit Wilson Kelley A, 6/13/2017

7 D OE S T H E D I ET R E A L LY W O R K? THE EVIDENCE : INITIAL RESEARCH s several dietary sugars recognized as IBS symptom inducers during high dose challenges but lacking applicability WKA2 Mid 2000 effects of fructose, FOS, and lactose gained significant attention and the concept of FODMAPs as a whole emerges by researchers at Monash University WKA3 Gibson PR, Shepherd SJ. Personal view: food for thought Western lifestyle and susceptability to Crohn s disease. The FODMAP hypothesis. Ailment PharmacolTher. 2005; 21 (12): Shepherd SJ et al. Randomised, placebo-controlled evidence of dietary triggers for abdominal symptoms in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2008; 6(7): WKA5 The Monash University Low FODMAP diet created in 2012 WKA4 FODMAPS AND IBS Efficacy: Two recent single blind placebo-controlled RCTs Halmos et al 54 subjects, 21 day crossover feeding controlled, LFD resulted in improvement in overall GI symptoms for 70% of patients. (the 1 st placebo controlled low FODMAP intervention trial) Staudacher et al 104 subjects, 4 weeks with dietary advice as a main feature, significantly improved on LFD. Comparative trials to traditional IBS diet Bohn, et al 75 subjects, LFD versus NICE for 4 weeks, without difference between diet treatments. Eswaran et al 84 subjects, LFD versus mod NICE for 4 weeks, no sig difference in composite end point responders but significantly improved abdominal pain on LFD and greater reductions in individual sx. 5

8 Slide 14 WKA2 however information on the composition of foods for these sugars was limited Wilson Kelley A, 6/13/2017 WKA3 who continue to publish most of the available FODMAP food composition data Wilson Kelley A, 6/13/2017 WKA4 since then various other tools have been created to help patients navigate a low FODMAP diet, which we will discuss later on Wilson Kelley A, 6/13/2017 WKA5 several studies down regarding the mechanism of action of FODMAPs using breath testing and the ileostomy model Wilson Kelley A, 6/13/2017

9 FODMAPS AND IBD Prince et al case note review of 88 subjects comparing symptom scores at baseline to 6 week LFD found significant decrease in severity of most symptoms and composite sx scores. Pederson et al RCT of 89 subjects with IBD (mild-mod or in remission and IBS like sx) on diet treatment x 6 weeks showed significantly improved sx and QOL in LFD group. Gearry et al retrospective study with 72 IBD pts, 50% were responders in multiple symptoms except for constipation W H O M AY B E N E F I T F R O M A LO W F O D M A P A P P R O A C H? 6

10 TARGET POPULATION - IBS WKA8 The target population is those with IBS, other diagnoses have been ruled out and standard therapies have failed to provide relief IBS can occur in isolation or may be underlying with: Inflammatory bowel disease Celiac disease Short bowel syndrome GERD Patients who are willing and able to complete a low FODMAP approach A low FODMAP diet is safe for most people, in the short term WHO SHOULD NOT USE THE DIET OR WHERE TO USE CAUTION Unintentional weight loss or malnutrition Hereditary fructose intolerance Diets or lifestyle choices that have led to avoiding entire food groups Patients with significant fear of foods or eating Medical conditions or medication regimens which may make it difficult to adhere to a low FODMAP diet approach Some patients with history of intestinal strictures Pregnant or breastfeeding patients Patients who have not been adequately worked up for possible other causes - Celiac disease - Biliary disease - Inflammatory bowel disease - Bacterial Overgrowth - Constipation - Eating disorders POTENTIAL UNDESIRABLE EFFECTS OF A LOW FODMAP DIET APPROACH Weight loss Constipation Worsened food aversion Too low fiber intake if patient cannot transition Frustration and distrust Potentially harmful gut flora changes WKA7 7

11 Slide 19 WKA8 the most commin GI disorder of western society, typically diagnosed via Rome IV criteria Wilson Kelley A, 6/13/2017 Slide 21 WKA7 FODMAPs have many benefits due to the fact that they ARE malabsorbed. Including natural laxation, prebiotic effect, and fermntation by products including SCFAs. Wilson Kelley A, 6/13/2017

12 T H E LO W F O D MA P D I ET APPR OACH N O T A O N E S I Z E F I T S A L L ROLE OF THE RD Complete nutrition assessment - (PMH, medications and supplements, symptoms, dietary intake, anthropometrics, etc) Ensure low FODMAP diet approach is appropriate Assist patient with navigation of the diet and management of intolerances Communicate findings and progress with referring provider, when/if necessary Take home messages for patient upon diet completion: - Manage symptoms with goal of least restrictive diet possible - This isn t a diet of complete avoidance - Learning is lifelong, as with any diet DIET APPROACHES There are 3 approaches to the diet: A generally low FODMAP diet The FODMAP elimination diet RD assistance recommended Targeted FODMAP treatment RD assistance recommended 8

13 A GENERAL LOW FODMAP DIET How To: Reduce overall FODMAP intake for 4-8 weeks and monitor symptoms PROS Easier to perform Less restrictive Easier to teach May lead to better compliance CONS May not lead to best symptom relief May take longer to reach relief Less likely to identify specific intolerances to individual FODMAP groups Education materials recommended: HFFY The low FODMAP diet approach to IBS THE FODMAP ELIMINATION DIET How To: Strictly avoid high FODMAP intake for 2 weeks, followed by systematic reintroduction of each FODMAP group one at a time PROS Typically more effective Pinpoints intolerances more specifically Able to better identify threshold of intolerance More focused treatment options CONS More restrictive (initially) More difficult to complete Extensive meal planning Focus on portion control Food label reading Nutrition risks of long term elimination Education materials recommended: The FODMAP toolkit, by Patsy Catsos, MS, RD Adapted from IBS-Free at Last! Second Edition. TARGETED FODMAP INTOLERANCE TREATMENT How to: RD provides recommendations based on known intolerances and/or food frequency questionnaire Patients may have strong suspicions, but do not know how the food triggers work or what dietary modifications and management strategies may help The patient s diet may be predominant in one or two FODMAP groups Examples: patient with gluten-free vegan lifestyle patient knows milk is a trigger, but does not know why Education materials used may vary. 9

14 TREATMENT AND FOLLOW UP Specific and individualized per patient results and needs TREATMENT Limit or avoid offending FODMAPs Spread intake throughout day Digestive enzymes Alpha-galactosidase Lactase Xylose Isomerase Food label reading May advise on additional nutrition recommendations based on the individual FOLLOW UP MAY BE NEEDED: Significant or multiple intolerances Patient develops fear of eating Dietary quality has been compromised Undesired amount or rapid weight loss has occurred RECOMMENDED RESOURCES The IBS Elimination Diet and Cookbook by Patsy Catsos MS, RDN, LD The Monash University Low FODMAP Diet phone app and online resources Kate Scarlata (RD) blog and website FUTURE DIRECTION OF FODMAPS Inflammatory bowel disease Colic SIBO management FODMAP certified dietitians FODMAP certified menus FODMAP certified food products and medical foods 10

15 C A S E S T U D Y APPLICATI ON CASE STUDY #1 R.Z. is a 59 year old male who complains of many years of fluctuating constipation, diarrhea, bloating, and excess flatulence. PMH significant for hypertension, benign prostatic hypertrophy, and chronic low back pain. He is 5 11 and weighs 210lbs. GI workup includes celiac disease serology, stool studies, H. pylori testing all negative. He feels that food triggers his symptoms, but is not sure which ones. I ll do anything to make this go away. His dietary intake is as follows: Breakfast high fiber granola bar and apple and glass of low fat milk Lunch ham and American cheese on wheat bread, baked potato chips, and V8 juice Dinner typically meat with potatoes/pasta/beans and a vegetable like corn or broccoli Snack low fat ice cream, sugar-free chocolate candies I m trying to choose healthier foods Fluids mostly water, occasional wheat beer but I pay for it Should the patient try a low FODMAP diet? If so, which approach? CASE STUDY #2 M.G. is a 33 year old female who complains of chronic constipation, abdominal pain, and bloating. PMH is significant for anxiety, depression, underweight status, GERD, and dysmenorrhea. She is 5 4 and weighs 101lbs. Workup includes EGD, colonoscopy, anorectal manometry, abd xray, which were all WNL. She takes laxatives but this leads to undesirable watery diarrhea. She endorsed feeling reluctant to see a dietitian, but her GI provider felt diet modification might be a helpful next step. Her dietary intake is as follows: Breakfast typically 2 servings fruit, rice cereal with fat free milk Lunch often skips Dinner chicken or turkey, 2-3 servings vegetables, avoids most grains besides rice Snacks none Fluids water, diet tea, coffee, aloe vera drink Should the patient try a low FODMAP diet? If so, which approach? 11

16 CASE STUDY #3 P.L. is a 23 year old female who complains of worsening reflux and bloating, despite remission from crohns disease. Bowel movements have been fairly normal. PMH significant for crohns disease and migraines. She is 5 0 and weighs 115lbs. GI workup includes recent EGD and colonoscopy, ESR/CRP which demonstrate remission from IBD. A lot of foods bother me, especially lactose, beans, and onions. Her dietary intake is as follows: Breakfast golden grahams cereal with soy milk, banana Lunch turkey and American cheese on white bread, yogurt, and mandarin oranges Dinner typically chicken or fish with pasta or couscous, or stir fry with variety of veggies Snack hummus with saltine crackers, string cheese Fluids mostly water, chamomile tea, carnation instant breakfast pre-made Should the patient try a low FODMAP diet? If so, which approach? REFERENCES Halmos, E.P., Power, V.A., Shepherd, S.J., Gibson, P.R., and Muir, J.G. (2014) A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome. Gastroenterology, 146 (1): Staudacher, H.M., et al. (2016) The Low FODMAP Diet Induces Symptoms of Irritable Bowel Syndrome Compared With Placebo Diet and the Microbiota Alterations May Be Prevented by Probiotic Co-Administration: A 2x2 Factorial Randomized Controlled Trial. AGA Abstracts, S-230:1133. Bohn, L., et al. (2015) Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as Well as Traditional Dietary Advice: A Randomized Controlled Trial. Gastroenterology, 149: Eswaran, S.L., et al. (2016) A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Gastroenterology, 111: Price, A.C., et al. (2016) Fermentable Carbohydrate Restriction (Low FODMAP Diet) in Clinical Practice Improves Functional Gastrointestinal Symptoms in Patients with Inflammatory Bowel Disease. Inflmam Bowel Dis; 0:1-8. Pedersen, N., et al. (2017) Low-FODMAP diet reduces irritable bowel symptoms in patients with inflammatory bowel disease. World J Gastroenterol, 23 (18): Gearry, R.B., et al. (2009) Reduction in dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease a pilot study. J Crohns Colitis. 3(1): Mansueto, P., Seidita A, D Alcamo, A. & Carroccio, A. (2015). Role of FODMAPs in Patients With Irritable Bowel Syndrome. Nutrition in Clinical Practice, 20 (5): De Giorgio, R., Umberto, V., & Gibson, P.R. (2016) Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction? Gut, 65,: Marsh, A., Eslick, E.M., & Eslick, G.D. (2015). Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. European Journal of Nutrition, Q U E S T I O N S? T H A N K Y O U! 12